Validity and reliability of the Greek version of Pregnancy Outcome Questionnaire (POQ)

Abstract Background During the last decades a considerable increase in biological and psychosocial approaches have occurred so as to enhance the study of prenatal period. This study aimed to investigate the validity and reliability of the Greek version of Pregnancy Outcome Questionnaire (POQ) in assessing pregnancy-related stress. Material and methods The study group consisted of 135 first-time expectant women with good knowledge of the Greek language, low-risk pregnancies and a gestational age of ≥24 weeks. Questionnaires containing the POQ scale questions in addition to other questions and scaleswere distributed in printed and digital format at private gynecological clinics. The collected data were analysed using the SPSS software. Results The POQ scale score showed satisfactory reliability (Cronbach’s alpha = 0.8), while the factor analysis showed a major factor with an eigenvalue of 4.17 and an overall interpreted factor variance of 41%. The sample showed moderate intensity values on the scale. We observed that pregnancy-related characteristics affected the scale, while no significant correlations with demographic variables were recorded. Conclusion The results of the reliability and factor analyses evaluating the scale structure indicated that the tool performed well in Greek, had a compact structure with satisfying reliability, and is suitable for use in the Greek pregnant population. However, additional research is warranted to investigate the effect of various additional factors on the scale.


Introduction
Pregnancy changes a woman's life prospects and may have significant implications for her health, well-being and social roles [1,2]. The stress rate experienced during pregnancy is higher than that of the general population. Pregnancyrelated anxiety is a multidimensional type of anxiety; its definition varies from general anxiety and depression [2,3,4]. Furthermore, it affects both the mother and the child [5] and may occur in 14.4% of pregnant women [4]. The attributes of this type of stress relate to pregnancy-specific fears and concerns around the foetus' well-being, childbirth per se, body and appearance issues, and puerperium [3,6]. Bayrampour et al. [5] defined pregnancy stress as 'nervousness and fear about the baby's health, mother's appearance and health, experience of the healthcare system, pregnancyrelated socioeconomic factors, labour, and parenthood; all of which are accompanied by intense anxiety and physical symptoms'. Significant evidence has gathered on the association between pregnancy-related stress and adverse birth outcomes with an increasing number of measures of this type of stress Greek language and a gestational age of ≥24 weeks. The criterion of primiparous subjects was applied taking into consideration that women who have already delivered a baby once, have the experience of transition into motherhood and, therefore, know what to expect from the process of childbirth and parenthood [12].Women may experience anxiety or fear over the upcoming changes, when becoming mothers for the first time [13]. Additionally, participants were asked to answer the questionnaire when reaching a minimum gestational age of 24 weeks, because from this week onward, extremely premature neonates demonstrate slowly increasing chances for survival [14]. The data were collected between July 2021 and October 2021. A total of 135 pregnant women responded to the questionnaire.

Data collection
Questionnaires were distributed in printed and digital format using Google Documents. It has been shown that answering online surveys does not differ significantly from the traditional paper-and-pencil method [15]. Points of distribution were private obstetric/gynaecological clinics. Questionnaires were handed out by midwives only to gestating women/mothersto-be whose current obstetric history indicated a low-risk pregnancy. The participants' demographic characteristics and personal and reproductive history were collected at the beginning of the questionnaire using questions on age, marital status, education, family income and obstetric history associated with possible previous pregnancies (childbirths and miscarriages).

Tools
The POQ scale was designed by Theut et al. [8] to examine the following hypothesis: in a pregnancy that follows a perinatal loss, parents experience pregnancy-specific stress rather than general stress. The construction methodology was based on interviews with couples expecting a child and having a history of perinatal loss [3], including miscarriage (early prenatal loss). The POQ scale addresses both first-time parents and those who already had a pregnancy in the past [8]. The POQ's 15 questions are graded on a Likert scale from 1 to 4, where 1 represents 'never', 2 'occasionally', 3 'often', and 4 'almost always'. Some questions are reverse-scored. The scale scope range is 15-60 when treated as a sum and 1-4 when treated as an average. Regarding reliability, studies have reported Cronbach α reliability index values of 0.8. Regarding validity, the tool is successfully differentiated into anxiety values among pregnant women, with and without a history of perinatal loss, in terms of the degree of concern they express about their pregnancy outcome [16,17]. The POQ scale was translated and weighted in Greek, by Tsartsara Eirini [16].
being developed worldwide. However, the introduction of these measures has not always been theoretically or psychometrically grounded, resulting in questions about the quality and direction of such research [7]. The Pregnancy Outcome Questionnaire (POQ) scale aims to assess the concerns of pregnant women regarding the outcome of their pregnancy. Four studies have used the POQ developed by Theut in 1988 [8], which was introduced specifically for the evaluation of anxiety in pregnancy subsequent to perinatal loss [8,9,10,11]. The scale comprises 15 questions addressed to gestating women, with or without a history of perinatal loss (Appendix). Moreover, it evaluates the intensity of pregnancy-specific and motherhood-related preoccupations of the expectant mothers. This study's objective was to investigate the validity and reliability of the Greek version of the POQ in assessing pregnancy-related stress in women with or without, a history of perinatal loss.

Ethics
The study was approved by the Institutional Review Board. The participants were chosen according to their availability and their willingness to take part in the research, in order to avoid affecting the results by unwilling participation. Eligible women were approached by trained research assistants as they awaited care in the prenatal care facility centre. Interested women were provided information about the purpose and nature of the study. Those meeting eligibility requirements and willing to participate provided their signatures to indicate informed consent to complete the questionnaire and to allow access to their medical charts. To minimise participant burden, questionnaires were completed in a private room at the prenatal care facility while participants awaited scheduled appointments. Before answering the questionnaire, all participants received a consent form describing the purpose of the research, type and processing of data to be collected, and personal data protection policy according to Helsinki Declaration and its later amendments. Informed consent was given by all participants before completing the questionnaire. In the absence of informed consent, they were excluded from the study.

Participants
We recruited pregnant women who were monitored in six private clinics and would mostly give birth in private maternity hospitals in Athens. The inclusion criteria were pregnant women, an age limit of≥18 years, first-time pregnancy after natural conception (preferably), good knowledge of the

Statistical analysis
The data collected were appropriately coded and processed via SPSS v.24.0 software. Cronbach's alpha index was calculated to assess the reliability of the study scales [18]. The t-test for two groups and the analysis of variance (ANOVA) for three or more groups were usedto test the statistically significant between-group differences of the scale means. Furthermore, to confirm the structure of the scale, the factor analysis method was implemented with the principal component analysis technique.

Results
The subjects of the study aged between 22 and 50 years (mean = 33.2, standard deviation [SD] = 5.16), while the average gestational week at the time of answering the questionnaire was 29.40 weeks (SD = 4,78). The absolute and relative frequencies of demographic characteristics and pregnancy are shown in Tables 1 and 2, respectively. The reliability of the scale, measured using Cronbach's alpha index, was 0.821, while removing the indicators 'Cronbach if item deleted' showed no improvement of the reliability index value in any question. Table 3    Abbreviations: POQ, Pregnancy Outcome Questionnaire; SD, standard deviation

Discussion
Pregnancy outcomes depend on a complex network of interactions between the care provided, the individuals concerned and the context in which they occur [19].
Significant evidence has accrued on the association between pregnancy-specific stress and unfavourable birth outcomes with an increasing number of measures of pregnancy-specific stress being developed, worldwide [20]. High-quality valuebased prenatal care can avoid or lead to timely recognition and treatment of maternal and foetal healthcare costs.
behavioural implications of pregnancy-related stress seem to serve as important indicators of the severity of the condition. Anxiety, depression and stress during pregnancy can adversely affect perinatal outcomes for mothers and children. Particularly, anxiety in pregnancy is strongly related with shorter gestation and has unfavourable implications for foetal neurodevelopment and child outcome. Identification of this unique form of stress (linked with many harmful effects) can provide the opportunity for early prenatal diagnosis and timely intervention, with the potential result of an optimal course of pregnancy.
The results of the reliability and factor analyses evaluating the scale structure demonstrated that the tool performed well in Greek, had a compact structure with satisfying reliability and is suitable for use in the Greek population. Future studies should also explore pregnancy-specific stress in women following an assisted reproduction technology, for whom the years of trying to conceive are longer in most cases. Further research should (a) examine the validity of the POQ in other populations of different language and/ or culture and settings, to ensure that the questionnaire is psychometrically sound, and (b) investigate its evaluative properties to determine its usefulness as a clinical outcome measure in maternity health services research.

Conclusion
Research and screening of pregnancy-related stress is restrained by a dearth of reliable psychometric evidence on self-report anxiety measures used in perinatal populations.  [17] claiming that none of the examined demographic characteristics affect gestational stress.
It has been reported that POQ assesses pregnancy-specific stress in gestating women with a history of perinatal loss, and the way stress increases the occurrence of such a history in subsequent pregnancies. Conversely, most subjects of our study had no history of perinatal loss; as a result, we evaluated the POQ scale regardless of a history of miscarriage. Therefore, this tool may assess gestational stress in pregnant women regardless of their known obstetric history. We found a statistically significant positive correlation between POQ and the years of effort to conceive. Particularly, the concern about the outcome of the pregnancy intensifies when the years of effort to conceive increase, irrespective of a possible history of perinatal loss. This result has not been reported by previous studies.
In contrast to other studies using POQ to assess gestational stress [9,10,17,21], we found no association with past miscarriage. This may be attributed to the fact that only 23% of our sample had a miscarriage in the past. Unlike former studies, our sample size was large (135 women). Particularly, apart from the work by Hutti et al. [21] containing a larger sample than ours, all studies using POQ enrol a sample of <50 individuals [9,10,17]. Nevertheless, this study is faced with certain limitations. The sample, albeit larger than that examined in previous studies employing the POQ scale, was not random; it involved pregnant women who received prenatal care in private clinics and would give birth in a private hospital. It is impossible to know whether the women participating in the study were at greater risk of experiencing specific gestational stress compared to the general pregnant population in Greece. Additionally, we did not include many women whose impregnation was induced by assisted reproduction, although they are reported to have higher rates of gestational stress than naturally conceived pregnancies [22,23]. However, we believe that these limitations do not decrease the importance of the findings. Thus, the research provides sufficient data for the reliability and validity of POQ in Greek. Pregnancy-related stress is a distinct type of stress. The key characteristics of prenatal stress are similar to those defined for anxiety disorders. It is critical to identify the signs, symptoms and diagnostic thresholds that warrant prenatal intervention and to build up efficient, helpful and valid screening tools and intervention strategies to be extensively used. The